Wound care and Dressings

1. Wound care and Dressings PN 103

2. Multiple types!!!!! • -wounds depth • -amount of drainage • -location of the wound. • -needs a MD/PA/NP order • -Follow protocol at your facility • -some facilities have pre-written orders depending on • the type of lesion. Types of Dressings

3. Surgical incision- • -Clean, well approximated edges, minimal • drainage • 1. Clean incision with wound cleanser • 2. Dry, sterile dressing (DSD)

5. -Open incision, moderated drainage • -packing with normal saline wet to dry dressing • -gauze strips • -Iodoform, Nu- gauze • -Skin prep to surrounding skin • -Cover with absorbent dressing • -Exudry, ABD-abdominal dressing

7. Pressure and stasis ulcers Wound bed applications • -granulating tissue • -usually nothing • -non-granulating tissue • -hydrating gels • -Xerophorm/Vaseline gauze

8. -slough • -saline wet to dry • -Dakins solution • -silvadene crème • -eschar • -debriding ezymes • -Dakins solution • -large/copious drainage • -alginate

9. -Infected/odiferous wounds- • -silver nitrate patches/gels, -anti-fungal gels

11. Packings- • -tunneling/undermined wounds • -Gauze strips- • -Iodophorm, Nu-gauze • -pack lightly with Q-tip • -allows granulating tissue to form

12. Dressings- • Thin- • -little/no drainage -protection • -transparent (Opsite) • -hydrocolloids (Duoderm, Gentleheel) • -foam (Allevyn, Optifoam), • -gauze (Telfa

13. Absorbent dressings- • -moderate/large amount of wound drainage • -abdominal dressing (ABD), Exudry

14. Tape -paper -clothe (silk, Medipore) -steri-strips -Montgomery straps Wraps -gauze wraps (Kerlex -ace wraps -Coban Etc. -Surgiflex, Band net

15. Allergic reaction to the tape adhesive • -blistering (tape burns) • Avoid tape to fragile, thin skin if possible

16. Monitoring Wounds • Frequency • -returning from surgury • -wounds appearance changes • -Increased odor/purulent drainage • -another care setting • -each dressing change • -Daily-acute care setting • -On admission-long-term care facility • -once a week there after

17. Signs of healing- • -Decreased size of the wound • -Decreased drainage • - Increased epitheliazation from the edges • to the center of the wound • -scar

18. Signs of wound deterioration -Increased drainage/odor -Erythema - wound and surrounding skin -Pain -Increased size -Change in wound drainage color

19. Documentation- • -size • -drainage (color, amount) • -appearance • -surrounding skin • -associated pain

20. Documentation- • -size • -drainage (color, amount) • -appearance • -surrounding skin • -associated pain

21. Wound Evaluation- • -Outcomes based of planning, nursing diagnosis's and goals • -if goals are not reached -examine the nursing interventions and strategies, then reassess. -create new goals and modify interventions

22. Case Study • A patients right heel ulcer is not healing. She is a resident in a long term care facility • How can the care plan be changed to meet the goals of having the right heel ulcer heal with out signs of infection?

23. . Float heels when in bed. • 2. Change the dressing regime. • 3. Padded boots when in bed. • 4. Elevate the feet as much as possible • 5. Sitting up in the wheelchair with legs elevated only for meals. • 6. Evaluate and measure right heel wound every 3 days x 2 then if healing, evaluate and measure weekly

24. Therapeutic High Protein Diet • _Components • 1. High protein • -animal proteins • -vegetable proteins (legumes, soy) • -supplements (Ensure, Boost, • Glucerna, Promod) • 2. Vitamin and Mineral Supplements • -leafy green vegetable, citrus fruit • -multivitamin with minerals

25. 3. Fluids/Hydration -1.5-2 liters fluid/day -avoid caffeine drinks -acts as a diuretic -encourage water!

26. http://www.youtube.com/watch?v=NGocVyrCkC8